URINARY TRACT INFECTIONSURINARY TRACT INFECTIONS33rdrd Y Med Students Y Med Students

Prof. Dr. Asem ShehabiProf. Dr. Asem Shehabi

Faculty of Medicine, University of Faculty of Medicine, University of JordanJordan

Urinary Tract Infections-1Urinary Tract Infections-1 Normal urine is sterile in urinary bladder.. It contains fluids, salts, Normal urine is sterile in urinary bladder.. It contains fluids, salts,

and waste products, but should be free of any microorganism.and waste products, but should be free of any microorganism. First portion of urine might be contaminated with few resident First portion of urine might be contaminated with few resident

microorganisms during it passages through urethra .. microorganisms during it passages through urethra .. More in More in women than Men. women than Men.

Urinary tract infection Urinary tract infection (UTI) (UTI) occurs often when bacteria from the occurs often when bacteria from the intestinal tract, contaminate the opening urethra and begin to intestinal tract, contaminate the opening urethra and begin to ascend & multiply causing ascend & multiply causing inflammation of any part of urinary tract inflammation of any part of urinary tract System.System.

UTIUTI is defined as a significant is defined as a significant bacteriuriabacteriuria associated with associated with presence of signs & symptoms or presence of signs & symptoms or asymptomaticasymptomatic

Urinary Tract Infections-2Urinary Tract Infections-2 DysuriaDysuria painful urination including burning, frequent painful urination including burning, frequent

urination , fever, abdominal pain ..Due to presence of urination , fever, abdominal pain ..Due to presence of Pus Pus cells & Bacteria cells & Bacteria in urine , Urinary Stones, Sexually in urine , Urinary Stones, Sexually Transmitted infection.Transmitted infection.

Sterial Pyuria: Sterial Pyuria: Presence of pus cells in urine. Presence of pus cells in urine. CystitisCystitis:: Inflammation of the Inflammation of the lower urinary tractlower urinary tract

urethra and Bladder mucosa.. mostly by bacteria. urethra and Bladder mucosa.. mostly by bacteria. This infection is not invasive.. It is Frequently This infection is not invasive.. It is Frequently associated with voiding frequent small volume urine, associated with voiding frequent small volume urine, can be can be mild/severemild/severe associated with high fever, associated with high fever, burning, abdominal pain, cloudy or bloody urine. burning, abdominal pain, cloudy or bloody urine. Rarely can be associated with Rarely can be associated with septicemiasepticemia.. Young .. Young children & Immunosuppressed patients.children & Immunosuppressed patients.

Hemorrhagic cystitisHemorrhagic cystitis is characterized by presence is characterized by presence large numbers of visible RBCs in the urine. large numbers of visible RBCs in the urine.

Urinary Tract Infections-3Urinary Tract Infections-3

PyelonephritisPyelonephritis:: Infection usually results from Infection usually results from ascending of the bacteria to theascending of the bacteria to the Ureter Ureter & & KidneyKidney from from the urinary bladder the urinary bladder caused by a bacterium..rarely Candida/ virus.. High fever.. may result in blood sepsis & kidney failure.

It can also arise by hematogenous spread (sepsis, It can also arise by hematogenous spread (sepsis, pneumonia). In contrast to cystitis.. pneumonia). In contrast to cystitis.. PyelonephritisPyelonephritis is is an invasive disease.. With severe consequences. an invasive disease.. With severe consequences.

Blood Sepsis Blood Sepsis may complicate UTI.. Common in may complicate UTI.. Common in children & women, following surgery, compromised children & women, following surgery, compromised patients.. patients.. Infection of upper part of UT

Urinary Tract Infections-4Urinary Tract Infections-4 UTIsUTIs caused by aerobic bacteria spp. of fecal origin.. caused by aerobic bacteria spp. of fecal origin..

90% of 90% of acute community UTIsacute community UTIs .. Developed in patients .. Developed in patients with normal anatomic structure and function caused by with normal anatomic structure and function caused by certain strains of certain strains of E. coliE. coli

Coagulase-negative & positive ve Coagulase-negative & positive ve StaphylococcusStaphylococcus caused about 10 %.. other caused about 10 %.. other G-veG-ve Klebsilla- Klebsilla- Enterobacter group, Proteus or G+ve Enterobacter group, Proteus or G+ve EnterococciEnterococci fecalis & others (5-10%). fecalis & others (5-10%).

Hospitalized patients Hospitalized patients acquired often UT infection with acquired often UT infection with multidrug resistance G-ve bacteria due to presence multidrug resistance G-ve bacteria due to presence MDR bacteriaMDR bacteria in their intestine & Hospital environment in their intestine & Hospital environment & following using & following using Foleys chatter.. Foleys chatter.. Nosocomail infection Nosocomail infection 5-15% . 5-15% .

Common: Common: P. aeruginosa, Proteus spp., Kelbsiella-P. aeruginosa, Proteus spp., Kelbsiella-Enterobacter group EnterococcusEnterobacter group Enterococcus spp. spp.

Urinary Tract Infections-5Urinary Tract Infections-5 UTI'sUTI's.. rank second to respiratory infections in .. rank second to respiratory infections in

general incidence. The majority of cases seen in general incidence. The majority of cases seen in outpatients clinics among outpatients clinics among Females Females (F/M ratio 30:1). (F/M ratio 30:1).

90% of all married women have at least one episode 90% of all married women have at least one episode of a UTI at some time during their productive years.of a UTI at some time during their productive years.

PregnancyPregnancy & women sexual activity increase UTIs 10 & women sexual activity increase UTIs 10 times..Up to 20 % of young women with acute cystitis times..Up to 20 % of young women with acute cystitis develop develop Recurrent UTI's. Recurrent UTI's.

Males develop increasing UTIs after Males develop increasing UTIs after >> 50s. mostly due 50s. mostly due to to prostate gland hypertrophyprostate gland hypertrophy..underlying diseases, ..underlying diseases, catheterization, diabetes mellitus, Immunosuppressed catheterization, diabetes mellitus, Immunosuppressed patients patients

In children congenital urinary tract abnormalities.In children congenital urinary tract abnormalities. kidney stones kidney stones can injury urethra or form a blockage & can injury urethra or form a blockage &

causing UTI. causing UTI.

Lab Lab Diagnosis-1Diagnosis-1 Routine Microscopic AnalysisRoutine Microscopic Analysis:: - Clean-catch - Clean-catch Midstream Urine Midstream Urine should be collected.. should be collected..

Early morning & examined within one hour of collection Early morning & examined within one hour of collection or refrigerated up to or refrigerated up to << 24h. 24h.

-- Symptomatic UTI Symptomatic UTI.... Acute Infection/ Significant Acute Infection/ Significant Bacteriuria: 100,000 colony-forming units (10Bacteriuria: 100,000 colony-forming units (1055CFU/ml) & CFU/ml) & Numerous WBCs ( Numerous WBCs ( >> 10 WBSc /HPF) 10 WBSc /HPF)

- - HematuriaHematuria: : Few RBCs in urine of women is not Few RBCs in urine of women is not significant.. But in men is Significant .. should be significant.. But in men is Significant .. should be investigated for other diseases. investigated for other diseases.

- Presence of few Bacteria /Yeast cells.. 10-50000 - Presence of few Bacteria /Yeast cells.. 10-50000 Cells/ml is part urethral normal flora..Cells/ml is part urethral normal flora..Not significant.Not significant.

- - Other important factorsOther important factors: Color, Protein, Sugar, pH : Color, Protein, Sugar, pH (5.5 to 6.5), Casts, Specific gravity etc.(5.5 to 6.5), Casts, Specific gravity etc.

Lab Lab Diagnosis-2Diagnosis-2 AsymptomaticAsymptomatic / /Chronic InfectionChronic Infection: 10.000-100,000 : 10.000-100,000

CFU/ ml of midstream urine..CFU/ ml of midstream urine..Few pus cellsFew pus cells.. 99% Pure .. 99% Pure Growth of one facultative anaerobic bacteria species . Growth of one facultative anaerobic bacteria species .

Presence 20.000 Presence 20.000 CFU/ ml or less with absence CFU/ ml or less with absence WBCs.. Mostly not significant. WBCs.. Mostly not significant.

Mixed Bacterial Cultures Mixed Bacterial Cultures are mostly contamination are mostly contamination except in case obstruction in UT/malignancy except in case obstruction in UT/malignancy

Suprapubic UrineSuprapubic Urine .. Any pure bacterial count in Infants .. Any pure bacterial count in Infants & Young children is significant& Young children is significant

Fresh urine samples should be cultured on Fresh urine samples should be cultured on Blood & Blood & MacConkeyMacConkey agar agar for recovery of both Gram+ve and for recovery of both Gram+ve and Gram-ve & Yeast,35-37C Incubation ..24-48 Hrs. Gram-ve & Yeast,35-37C Incubation ..24-48 Hrs.

E. coli – Lactose FermenterE. coli – Lactose Fermenter

Gram-stain & Culture on MacConkey agarGram-stain & Culture on MacConkey agar

Antimicrobial Treatment -1Antimicrobial Treatment -1 UTI UTI clinical manifestations , previous history of clinical manifestations , previous history of

infection, antibiotic susceptibility should quid the initial infection, antibiotic susceptibility should quid the initial step Antimicrobial Therapy. step Antimicrobial Therapy.

Community acquired infection Community acquired infection //OutpatientsOutpatients – A febrile patients experiencing first time uncomplicated A febrile patients experiencing first time uncomplicated

symptomatic.. symptomatic.. Acute cystitis Acute cystitis is usually treated empirically for is usually treated empirically for three days.. three days..

– First line: First line: Augumentin, Nitrofurantoin,  Cotrimoxazole , Augumentin, Nitrofurantoin,  Cotrimoxazole , Nalidix acid.Nalidix acid.

– Second lineSecond line: Fluoroquinolones..Norfloxacin/ Ciprofloxacin, : Fluoroquinolones..Norfloxacin/ Ciprofloxacin, 2nd-generation Cephalosporins ..Cefrouxime . 2nd-generation Cephalosporins ..Cefrouxime .

– Antibiotic prophylaxis against UTI should be given only in Antibiotic prophylaxis against UTI should be given only in

in selected clinical cases. in selected clinical cases.

Antimicrobial Treatment -2Antimicrobial Treatment -2-Recurrence of UTI's-Recurrence of UTI's within 2-3 months require within 2-3 months require

performing urine culture and antimicrobial performing urine culture and antimicrobial susceptibility test.. Often infection associated with susceptibility test.. Often infection associated with R- bacteria strainsR- bacteria strains. .

- Hospital acquired UTI's is often associated MDR Hospital acquired UTI's is often associated MDR bacteria.. require culture and susceptibility test. bacteria.. require culture and susceptibility test.

PyelonephritisPyelonephritis is more serious & difficult to cure..may is more serious & difficult to cure..may be associated septicemia.. followed reoccurrence be associated septicemia.. followed reoccurrence UTIUTI due to relapse (treatment failure) or re-infection, due to relapse (treatment failure) or re-infection, mostly with the same bacteria spp. mostly with the same bacteria spp.

Serious UTI : Serious UTI : Patients experiencing high fever, Patients experiencing high fever, shaking chills or abdominal pain with symptoms of shaking chills or abdominal pain with symptoms of lower UTI, should be hospitalized and treated with lower UTI, should be hospitalized and treated with intravenous drugs.intravenous drugs.

Treatment & PreventionTreatment & Prevention

A large number of pregnant women develop A large number of pregnant women develop asymptomatic bacteriuriaasymptomatic bacteriuria. .

Up to 30% with asymptomatic bacteriuria will develop Up to 30% with asymptomatic bacteriuria will develop acuteacute pyelonephritispyelonephritis if not treated. if not treated.

Treatment of asymptomatic bacteriuria in pregnant Treatment of asymptomatic bacteriuria in pregnant women decreases the risk of pyelonephritis, preterm women decreases the risk of pyelonephritis, preterm birth & baby low birth weight. birth & baby low birth weight.

Urine samples should be obtained periodically from Urine samples should be obtained periodically from pregnant women to determine if they have bacteriuriapregnant women to determine if they have bacteriuria..

Asymptomatic bacteriuria Asymptomatic bacteriuria in infants and Jung children in infants and Jung children

might be observed by crying, abdominal pain or might be observed by crying, abdominal pain or unexplained fever.unexplained fever.